Abstract
Background: Communication is a necessity of social life which is very important in health care settings due to the type of work and clients. The aim of this study was determine the association between interpersonal communication skills (ICSs) and personality dimensions of nurses working in Rafsanjan University of Medical Sciences.Materials and Methods: In this descriptive study, 223 nurses were selected by stratified random sampling method and they completed the Burton ICSs and the Revised NEO Personality Inventory ‎. Data were analyzed using the Pearson correlation, independent t-test, and multiple linear regression at a significant level of P = 0.050.Results: Among the selected nurses, 9.9%, 75.8%, and 14.3% had a poor, moderate and good communication skills respectively. The association between age (P = 0.026) and work experience (P = 0.025) with ICSs were inversely significant. There was a significant correlation between good communication skills and the extroversion personality aspect (P = 0.001), pleasure (P < 0.001), and accountability (P = 0.039). The pleasure and extroversion were able to predict and explain 8.7% of the ICSs nurses.Conclusions: More than half of the nurses had difficulties in ICSs. The communication pattern of nurses is effective in their performance and quality of work; therefore, their personality dimensions and traits can be taken into account in the process of recruiting, transferring, or moving them. Hence, each person can be appropriately located in the right place in terms of the area of activity, and type and number of clients.

Keywords: Communication, Skill, Personality, Nurse, Iran

Introduction
The human being is a social being and this characteristic requires communication with others. The exchange of ideas, beliefs, and feelings initiates through the process of communication (1). Individuals communicate in various ways through the responsibility and professions they have in the community. One of the occupations in the success of which communication has a special role is nursing. Nurse-patient communication is a professional type of communication based on trust and mutual respect (2, 3).
Through establishing effective communication, the quality of health improves (4), patient safety is provided (5), and patient satisfaction, which is the ultimate goal of any health care system, increases (6). In this regard, Bahr et al. pointed out the important role of communication of the treatment team, especially the nurses, at the time of discharge, and considered it as a factor in preventing re-admission of the patient due to recurrence of the disease (7). Flanagan et al. declared poor nurse-patient communication and weak nursing responsiveness to patient needs as the two important factors of the three factors involved in disease progress and re-admission of patients (8); to the extent that some researchers have stressed how to train nurses on effective communication both theoretically and using a simulated patient (SP) (9).
Communication is an active process; therefore, it can be influenced by various environmental or interpersonal factors (10). The personality pattern of individuals seems to be one of the important factors influencing their communication pattern (11). Personality is the largest, most powerful, and most effective factor of stability affecting the attitude, feelings, beliefs, and behavior of the humankind. McCrae and Costa’s five factor model (FFM) is one of the most influential and most important models in the study of personality traits and examines the 5 main dimensions of personality including neuroticism, extroversion, experientialism, acceptability, and conscientiousness (12).
According to the studies by Plonien and Götlind, personality factors are effective in the communication of nurses as the most important element in the recovery of patient health (13, 14), as personality and personality traits form the basis of behavior, thoughts, and emotions of the individual (15). Sabzi and Yousefi reported in their study that personality traits of individuals can determine their social relationships (16). In this study, extraversion was a positive and significant predictor and a negative predictor of emotional regulation and insight in the communication, respectively. In addition, the neuroticism personality dimension was a negative predictor of perception of verbal and nonverbal messages and emotional regulation (16). In two other studies, the researchers reported that there was a positive and significant relationship between personality traits and communication skills (17, 18). Therefore, investigation of personality traits of nurses is of particular importance and is taken into account as an important factor in demonstrating their ability to provide patient care services for patients and their resilience in the hospital environment. Effective communication with patients and their companions and other health care professionals is essential to nursing (19). Therefore, determination of the level of interpersonal communication skills (ICSs) of nurses and their relevant and influential factors is one of the requirements for improving the quality of services and enhancing satisfaction (6). Therefore, the present study was conducted with the aim to determine the ICSs of nurses and their relationship with personality dimensions.

Material and Methods
The present study was a descriptive study with a statistical population including all nurses (N = 510) working in Ali-ibn Abi Talib, Moradi, and Niknafs Hospitals affiliated to Rafsanjan University of Medical Sciences, Rafsanjan, Iran, in 2015. The sample size was calculated using the Cochran formula:
Due to the lack of access to the estimate of the ratio, the maximum value of 0.5 was considered for P; in this case, the q-value would also be 0.5. The sample size based on the community size (N), the degree of confidence (d), and the standard percentage error of the acceptable reliability coefficient (z) of, respectively, 510, 0.05, and 1.96 was obtained as 217 individuals. Then, taking into account a potential drop of 10%, 240 nurses were selected using stratified random sampling method (based on the proportion of women to men) and entered the study. Finally, 223 assessable inventories were returned (response rate of 92.92%).
The study inclusion criteria included employment during the study, having a work experience of more than 6 months, and having a bachelor's degree or higher degree. The study exclusion criteria were a history of mental illness causing hospitalization or prescription of drug treatment, a history of death of close relatives during the past 3 months, divorce during the past year, severe marital conflicts requiring psychological counseling, reluctance to participate in the study, and incomplete inventory form.
Initially, the list of nurses was taken from the university's nursing office, and then, the nurses were selected randomly based on the women to men ratio. Subsequently, the researchers received nurses’ working schedule from nursing offices of hospitals, and then, they referred to the nurses' workplaces and gave them the necessary explanations regarding the study objectives and how to complete the inventories. In the next step, the researchers assured the nurses that the inventories would be anonymous; in addition, they reassured them that their information would be examined confidentially and collectively. Then, after receiving informed consent from the patients, and in case of their passing the inclusion and exclusion criteria, they were provided with the inventories and were requested to hand them in to the hospital's nursing office within one day after completion.
A demographic characteristics checklist including age, sex, and work experience, the Revised NEO Personality Inventory (NEO PI-R), and Burton’s Interpersonal Communication Skills Inventory were used to collect data.
The original version of the NEO PI with 181 items was provided by McCrae and Costa in 1985, and after several revisions, its current version (NEO PI-R) includes 60 items (20). This inventory was translated into Persian and its factor structure was investigated by Garousi et al. This 5-factor inventory includes 60 items scored based on a 5-point Likert scale ranging from totally agree to totally disagree with a score range of 4 to 0, respectively; each 12 items are related to one of the five major factors of personality (neuroticism, extroversion, flexibility, pleasure, and accountability). The total score range for each scale was 0-48. This inventory does not have a total score. The higher the score is in any of the personality trait scales, the greater the severity of that trait is (21). In the study by Mirzaei et al., the Cronbach's alpha, total alpha, and total score retest validity of the factors of this inventory were obtained as 0.68 to 0.881, 0.95, and 6.033, respectively (22). In the present study, Cronbach's alpha of the neuroticism, extroversion, flexibility, pleasure, and accountability dimensions, and the total inventory were obtained as 0.68, 0.46, 0.68, 0.64, 0.84, and 0.72, respectively.
Burton’s Interpersonal Communication Skills Inventory consists of 18 items in 3 dimensions of verbal skill, effective listening skill, and feedback skill (23). The items are scored according to a 5-point Likert scale ranging from 1 to 5 (totally disagree to totally agree, respectively). Therefore, the range of the total score will be between 18 and 90. The higher the score is, the higher the individual's use of that communication skill is. In the study by Safavi et al., the total validity of the inventory was 0.880. Moreover, the total reliability of the inventory, and the verbal skill, listening skill, and feedback skill scales was 0.800, 0.715, 0.705, and 0.700, respectively (24). Furthermore, the Cronbach's alpha of the inventory in the present study was calculated to be 0.821.
Finally, the data were collected and analyzed in SPSS software (version 17, SPSS Inc., Chicago, IL, USA). The skewness and kurtosis of the interpersonal Communication Skills score were in the range of ± 2; in addition, the significance level of the Kolmogorov-Smirnov (K-S) test of this variable was less than 0.05. However, according to the central limit theorem (CLT) and the high sample size (25, 26), the Pearson correlation coefficient, independent t-test, and multiple linear regression (MLR) tests were used to analyze the data. The significance level of the tests was considered as 0.050.

Results
In total, 223 nurses with a mean±SD age of 31.43 ± 5.95 years (range: 21-52 years) and a mean±SD work experience of 7.23 ± 5.92 years (range: 1-30 years) were studied. Of these, 146 (65.5%) were women. Independent t-test results indicated that the mean age and work experience of men nurses were significantly higher compared to the women (P = 0.012 and P = 0.021, respectively).
The mean±SD of ICS score was 57.43 ± 8.54 and the highest mean score was related to the listening communication skill (19.63 ± 3.32). There was no significant difference between men and women nurses and married and single nurses in terms of ICS and its dimensions (P > 0.050) (Table 1).

Table 1: Mean scores of interpersonal communication skills among nurses of Rafsanjan University of Medical Sciences, Rafsanjan, Iran, in 2015 based on sex and marital status (n = 223)

Variable

Mean ± SD

Communication skill

Verbal Skill

Listening skill

Feedback skill

Total

57.43±8.54

18.81±3.37

19.36±3.32

18.99±3.16

Man (n = 77)

57.32±10.09

18.57±3.96

1.92±3.56

18.83±3.60

Women (n = 146)

57.49±7.64

18.94±3.01

19.48±3.19

19.07±9.92

P*

P= 0.849

P= 0.345

P= 0.440

P= 0.596

Single (n = 146)

54.20±9.02

18.67±3.61

19.52±3.24

19.01±3.33

Married (n = 74)

57.87±7.56

19.09±2.85

19.84±3.47

18.93±2.84

P*

P= 0.544

P= 0.454

P= 0.353

P= 0.893

SD: Standard deviation, * According to t-test

The analysis of the results showed that 22 (9.9%), 169 (75.8%), and 32 (14.3%) of participants had a poor, moderate and good communication skills respectively. The correlation of age and work experience with ICSs (P = 0.026, P = 0.008), good listening skill (P = 0.049, P = 0.013), and feedback skill (P = 0.001) was inversely significant (Table 2).

Table 2: Pearson correlation coefficients of interpersonal communication skill and its dimensions with age and work experience of nurses of Rafsanjan University of Medical Sciences, Rafsanjan, Iran, in 2015 (n = 223)

Variable

Communication skill

Verbal Skill

Listening skill

Feedback skill

Age

r= -0.149
p= 0.026

r= -0.046
p= 0.494

r- -0.132*
p= 0.049

r= -0.214**
p= 0.001

Work experience

r= -0.177**
p= 0.008

r= -0.081
p= 0.231

r= -0.166*
p= 0.013

r= -0.218**
p= 0.001

P<0.05*, p<0.01**, Pearson correlation coefficient

The five main patterns of nurses' characters were studied using the NEO PI-R. Comparison of scores revealed that the mean scores of extroversion, pleasure, and accountability of women nurses were significantly higher than those of the men nurses (P < 0.001). In addition, the mean score of neuroticism (P < 0.001) and flexibility (P = 0.013) of married nurses as well as the mean score of extroversion and pleasure (P < 0.001) of single nurses were significantly higher. The accountability of married and single nurses was not significantly different (P = 0.549).
The results of the Pearson correlation coefficient indicated that the relationship between ICSs of nurses and the personality dimensions of extroversion, pleasure, and accountability was significant (P = 0.001, P < 0.001, and P = 0.039, respectively) (Table 3).

MLR was used to predict communication skills of nurses based on personality dimensions. Statistical assumptions were reviewed. The predicting and dependent variables were quantitative and interval.. The normality of the distribution of error values was investigated. According to the CLT and the high sample size (25, 26), the K-S test significance level of the variables was less than 0.050. The multicollinearity was investigated among the variables and the collinearity assumption of the variables was rejected (VIF = 1.797-1.201, tolerance < 1.0). The independence of the errors was examined. The Durbin-Watson statistic was equal to 0.847, illustrating the lack of correlation among errors [regression equation was significant (P < 0.001)]. Moreover, 8.7% of the pattern of interpersonal ‎communication of nurses was determined based on personality dimensions. Among the personality dimensions, extroversion (P = 0.020) and pleasure (P = 0.003) were able to predict the ICSs of nurses (Table 4).

Table 4: Prediction of nurses' communication pattern in Rafsanjan University of Medical Sciences, Rafsanjan, Iran, in 2015 based on personality dimensions

Model

Unstandardized coefficients

Standardized coefficients

t

P value

B

Standard error

β

Fixed

40.15

5.03

7.99

P<0.00

Extroversion

0.189

0.081

0.165

2.34

P= 0.02

Pleasure

0.399

0.135

0.255

2.96

P= 0.003

Discussion
The results of this study showed that 85.7% of the nurses were not able to communicate interpersonally, and their ability to communicate, hear, and comment was mediocre. Findings of Rostami (27), Khadivzadeh (11), Barati (28), Javaher (29), McCabe (30), and Alasad (31) also confirmed the results of this study. However, Zeighami evaluated the communication skills of most nurses to be good (2). It seems one of the reasons for nurses' communication skills being average is similar and somewhat flawed education that is presented to nurses according to specific guidelines (32). Of course, the working environment of the nurses must be taken into account. The present study was conducted in governmental hospitals with the highest operational capacity in areas such as trauma emergency, pediatric emergency, general emergency, general surgery, orthopedics, internal medicine, obstetrics and gynecology, and specialized departments. These environments are stressful and patients have high expectation to receive the best services in the shortest possible time. Practically, these issues influence the nurse's energy and capacity and provided that the work environment is stressful, the nurse will suffer from burnout (33, 34), and consequently, the disorderliness in the relationship between the nurse and the patient is not unexpected (35). Without doubt, these issues should not be a justification of the problem.
In this study, the mean scores of interpersonal skills of male and female nurses did not show a significant difference. In this respect, it contradicted the results of Safavi and Barati which showed that female nurses were more capable in communication skills (24, 28).
In this study, there was a meaningful and inverse correlation between age and communication skills. This result was consistent with the finding of the study of Gholami (36) and contradicted that of the study by Amiri (37). Perhaps less fatigue due to work experience, less job burnout, or less family problems are the reasons behind better communication skills of nurses of younger age.
In this study, the correlation of nurses' ICSs with the personality dimensions of extroversion, pleasantness, and accountability was significant. Leung's belief is that the relationship between personality styles and personality patterns depends, to a large extent, on the individual's view of self and self-valuation (38). Riggio considers personality as an effective factor in communication and social competence of nurses (39).
Extrovert people have a more objective and outward view and their practical activity is of higher quality (40). These people would like to influence the work atmosphere, compete with others, and tend to appear more in public gatherings (41). The ability to control impulses and desires and usage of plans and schemes in behavior are the two main characteristics of responsible people in their attempt towards reaching their objectives (42, 43). In this regard, it can be said that nurses who are hopeful, and have a positive attitude towards the future and the ability of constructive thinking, can appropriately deal with the patients and establish a constructive relationship with them in the face of problems and unexpected events. Such characteristics also help them to be aware of the patient's conditions, and consequently, through a sense of gaiety and joyfulness and a promising speech, they increase patients’ hopefulness in the treatment and their recovery. As a result, the nurse will earn the patient's trust over the hospitalization period (44).
The results of this study showed correlation between the personality dimensions of extroversion, pleasantness, and responsibility and communication skills; thus, they contradict the findings of the studies by Kuntze et al. and Smith et al. (45, 46). Perhaps, in addition to intrapersonal issues such as personality, issues such as teaching effective communication (47), regional culture (10), patient’s behavior (48), and intra-organizational issues (3, 49) are also important in this regard. Getting the best and fastest health care with maximum safety is the right of every human being (50) and the nurse is at the forefront of providing these services in hospitals. In this regard, suitable communication along with adequate knowledge and a healthy personality are of the most important tools for professional and modern nursing (18).
This study also had limitations. First, in questionnaire studies, understanding of questions, bias, and self-expression are of the most important and influential factors in the accuracy and completeness of the answers. This can affect the degree of trustability and generalizability of the results.
Furthermore, inserting numerous questions in the questionnaires was of the other limitations of this study, which may result in boredom and decline in accuracy in completing the questionnaires. Finally, in this study, factors such as income, work shift, nurses' position, passing courses of effective communication, and the hospital section in which they were working were not considered. It is suggested that in future studies questionnaires with fewer items be used and the above factors (which were not included in this study) be taken into account.

Conclusion
The ICSs were at an average level among the majority of the nurses. This issue doubles the need for specialized training, review of various aspects of management, including manpower management, financial management, and welfare management; however, these factors were not investigated in the present study. Moreover, the conscientiousness personality dimensions were related to the communication skills of nurses. This can help authorities in selecting and arranging nurses in the desired wards. In this regard, considering personality traits through the use of personality tests or psychological interviews would be more beneficial.

Acknowledgment
Finally, the material and spiritual support of the Research Deputy of Rafsanjan University of Medical Sciences and patient collaboration of the nurses with the researchers in this study are sincerely appreciated.

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